Hospitals following heart attack guidelines have better outcomes

03/08/04

Eric D. Peterson, MD
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NEW ORLEANS -- In one of the first studies of its kind, Duke University Medical Center researchers have demonstrated clearly that hospitals' adherence to national guidelines for treating potential heart attacks saves lives.

This finding is important they said, because while many studies have proven the effectiveness of individual therapies in improving outcomes for heart attack patients, very few have correlated individual hospitals' use of these different therapies with how their patients actually fare.

For their study, the researchers consulted a database of 64,775 patients at more than 400 U.S. hospitals to determine how hospitals adhered to nine different quality measures of in-hospital and discharge care. Those hospitals in the top 25 percentile of adherence were deemed "leading," while the bottom 25 percent were "lagging."

"We found a large gulf in the outcomes between the two, with a mortality rate of 4.17 percent at the leading hospitals, compared to a 6.33 percent mortality rate at lagging hospitals," said Eric Peterson, M.D., cardiologist at the Duke Clinical Research Institute (DCRI). "This is one of the first studies that has linked adherence to established national guidelines to improved outcomes.

"Encouraging hospitals to systematically monitor the use of recommended therapies is one way to promote quality of care and improve patient outcomes," he added.

Peterson reported the results of the analysis March 10, 2004, at the annual meeting of American College of Cardiology (ACC).

Both the ACC and the American Heart Association have issued guidelines for optimal care of patients who arrive at hospital with symptoms of a possible heart attack, such as chest pain (unstable angina), irregular readings on an electrocardiograph or elevated chemical markers of cell death.

The guidelines were adopted after large-scale clinical trials demonstrated the effectiveness of these therapies in saving lives. The guidelines focus on giving suspected heart attack patients anti-platelet medications, heparin, glycoprotein IIb/IIIa inhibitors (clot inhibitors) or beta-blockers within the first 24 hours of admission, as well as prescribing such drugs as aspirin, beta-blockers, ACE inhibitors or statins after discharge.

For his analysis, Peterson consulted the database of a national quality improvement initiative known as CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC and AHA Guidelines).

CRUSADE maintains a national registry of data collected from more than 400 hospitals nationwide and then reports back to each hospital every three months on their adherence to the guidelines. CRUSADE is coordinated by the DCRI.

"CRUSADE patients are the "real world" patients that physicians see every day in all types of hospitals," Peterson said. "Other analyses based on clinical trials are not necessarily indicative of the population as a whole since they usually have many different exclusion and inclusion criteria.

"There were significant performance gaps between leading and lagging hospitals for each of the nine performance measures, ranging from narrow for initial aspirin use (96 percent vs. 85 percent) to wide for the use of GP IIb/IIIA inhibitors (50 percent vs. 17 percent)," Peterson said.

Compared to the lagging hospitals, leading hospitals tended to be larger with an average of 388 beds, compared to 321 for lagging hospitals. The leading hospitals were more often academic (34 percent vs. 21 percent) and they also tended to have the capability to perform cardiac catheterization and coronary artery bypass surgery.

"While the data generated by the CRUSADE initiative highlights weaknesses in the process of delivering health care, it clearly shows the areas that need improvement," Peterson said. "The goal of the program is to stimulate hospitals to re-evaluate their care processes."

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